What's keeping people after stroke from walking outdoors to become physically active? A qualitative study, using an integrated biomedical and behavioral theory of functioning and disability

Factors affecting community ambulation post-stroke: a mapping review protocol

Background

Most stroke survivors consider community ambulation an essential but unmet goal of their recovery. Historically, interventions to enhance community ambulation have focused on improving biomechanical impairments of gait; however, recent evidence suggests that biopsychosocial and environmental factors may impact community ambulation, even beyond more obvious physical impairments. The identification of factors that pose as significant facilitators or barriers to community ambulation may serve to guide stakeholders in designing relevant and evidence-based interventions for improving community ambulation post-stroke.

Objective

This review aims to map the type and extent of existing evidence on the physical, biopsychosocial, and environmental factors affecting community ambulation post-stroke. Additionally, this review will describe the various methods used to examine the extent to which stroke survivors are restricted to community ambulation.

Methods

Nine databases will be searched including CINAHL, PubMed, and Web of Science. We will include studies published in English during or after 2001. Studies that examine physical, biopsychosocial, and/or environmental factors affecting community ambulation in ambulatory adults at least six months post-stroke will be considered for inclusion. Studies that assess general physical activity or community mobility through transportation modes other than walking will be excluded. All identified records will be collated in citation management software, followed by steps of deduplication, title/abstract screening, and full-text reviews by at least two independent reviewers. The bibliographies of the extracted studies will also be reviewed for relevant articles. The extracted studies will be analyzed, critically appraised, and presented in tabular, narrative, and evidence map formats.

Discussion

The evidence gained will be used to build a framework for community ambulation, informing stakeholders to develop meaningful interventions to improve community ambulation. The mapped evidence will motivate future studies to develop holistic approaches that specifically focus on the most vital factors that influence post-stroke community ambulation.

Speed- and Endurance-Based Classifications of Community Ambulation Post-Stroke Revisited: The Importance of Location in Walking Performance Measurement

BACKGROUND

Gait speed or 6-minute walk test are frequently used to project community ambulation abilities post-stroke by categorizing individuals as household ambulators, limited, or unlimited community ambulators. However, whether improved clinically-assessed gait outcomes truly translate into enhanced real-world community ambulation remains uncertain.

OBJECTIVE

This cross-sectional study aimed to examine differences in home and community ambulation between established categories of speed- and endurance-based classification systems of community ambulation post-stroke and compare these with healthy controls.

METHODS

Sixty stroke survivors and 18 healthy controls participated. Stroke survivors were categorized into low-speed, medium-speed, or high-speed groups based on speed-based classifications and into low-endurance, medium-endurance, or high-endurance groups based on the endurance-based classification. Home and community steps/day were quantified using Global Positioning System and accelerometer devices over 7 days.

RESULTS

The low-speed groups exhibited fewer home and community steps/day than their medium- and high-speed counterparts (P < .05). The low-endurance group took fewer community steps/day than the high-endurance group (P < .05). Despite vast differences in clinical measures of gait speed and endurance, the medium-speed/endurance groups did not differ in their home and community steps/day from the high-speed/endurance groups, respectively. Stroke survivors took 48% fewer home steps/day and 77% fewer community steps/day than healthy controls.

CONCLUSIONS

Clinical classification systems may only distinguish home ambulators from community ambulators, but not between levels of community ambulation, especially beyond certain thresholds of gait speed and endurance. Clinicians should use caution when predicting community ambulation status through clinical measures, due to the limited translation of these classification systems into the real world.

Co-design of a walking activity intervention for stroke survivors

Introduction

Stroke survivors may not maintain gains made in gait performance after task-oriented circuit training. Behavior change interventions may enhance the long-term adoption of physical activity. This study uses a co-design methodology to develop an intervention and tools to facilitate physical and exercise therapists in supporting an active lifestyle in stroke survivors, which is defined as a lifestyle that integrates daily walking performance with day-to-day activity.

Objectives

(1) To describe the insights generated during the co-design process; and (2) To describe the tools that were developed during the co-design process.

Methods

A multidisciplinary team consisting of staff members of the Royal Dutch Society for Physical Therapy, exercise and physical therapists specializing in neurorehabilitation and conducting task-oriented circuit class training in primary care settings or day therapy centers within residential care facilities, stroke survivors and their carers, experts in measuring movement behavior in stroke survivors, a company specializing in manufacturing sensors and related software, behavior change specialists, and co-designers all collaborated in a three-stage (define, develop, and deliver) co-design process.

Results

In the design process, the team iteratively developed a prototype accelerometer system for measuring walking performance with a feedback function for stroke survivors and their therapists and a prototype toolbox for therapists to support the facilitation of behavior change in their stroke survivors.

Discussion

This study shows how co-design can be applied to develop interventions for stroke survivors. Both the prototype system for measuring walking performance and the toolbox incorporate behavior change techniques to support a more physically active lifestyle in stroke survivors. Further research will investigate the feasibility of the intervention.

Self-reported factors associated with community ambulation after stroke: The Canadian Longitudinal Study on Aging

Community ambulation is frequently limited for people with stroke. It is, however, considered important to people with stroke. The objectives were to identify factors associated with self-reported community ambulation in Canadians aged 45+ with stroke and to identify factors associated with community ambulation specific to Canadian males and to Canadian females with stroke. Data were utilized from the Canadian Longitudinal Study on Aging Tracking Cohort. Multivariate logistic regression models were developed for community ambulation. Mean age was 68 (SE 0.5) years (45% female). In the final community ambulation model (n = 855), factors associated with being less likely to 'walk outdoors sometimes or often' included difficulty or being unable to walk 2-3 blocks (decreased endurance) vs. no difficulty. Being more likely to walk outdoors was associated with 'better weather' months and being 55-64 years of age vs 75-85. Differences were noted between the models of only males and only females. Decreased walking endurance is associated with a decreased likelihood of walking in the community-a factor that can be addressed by rehabilitation professionals and in community based programs.

Factors related to high-risk movement behaviour in people with stroke who are highly sedentary and inactive

PURPOSE

To identify Capabilities, Opportunities, and Motivational factors influencing movement behaviour throughout the day in people with stroke who are highly sedentary and inactive to enable intervention development.

METHODS

A qualitative study was conducted using semistructured interviews with people with stroke. The interview guide was based on the Capabilities, Opportunities, and Motivation Behavioural model.

RESULTS

Eleven interviews were conducted. Participants reported a lack of knowledge regarding healthy movement behaviour patterns, a lack of insight into their own movement behaviour, and some physical and cognitive limitations to engage in certain physical activities. Several social and environmental elements affecting movement behaviours were mentioned, their impact on movement behaviour varied among participants. Movement behaviour was mostly driven by habits and daily routine, without conscious regulation.

CONCLUSION

Our findings show that people with stroke are unaware of their own movement behaviour or of the consequences of these behaviours on health. Movement behaviour is, for the most part, based on daily routine and personal habits. This indicates the need for a behaviour change intervention. Such interventions will need to include providing information about healthy movement behaviour, feedback on individual's movement behaviour and individualized support, taking into account the social and environmental context and personal capabilities.

Sympathetic nervous system responses during complex walking tasks and community ambulation post-stroke

Stroke survivors frequently report increased perceived challenge of walking (PCW) in complex environments, restricting their daily ambulation. PCW is conventionally measured through subjective questionnaires or, more recently, through objective quantification of sympathetic nervous system activity during walking tasks. However, how these measurements of PCW reflect daily walking activity post-stroke is unknown. We aimed to compare the subjective and objective assessments of PCW in predicting home and community ambulation. In 29 participants post-stroke, we measured PCW subjectively with the Activities-specific Balance Confidence (ABC) Scale and objectively through electrodermal activity, quantified by change in skin conductance levels (SCL) and skin conductance responses (SCR) between outdoor-complex and indoor-steady-state walking. High-PCW participants were categorized into high-change SCL (ΔSCL ≥ 1.7 μs), high-change SCR (ΔSCR ≥ 0.2 μs) and low ABC (ABC < 72%) groups, while low-PCW participants were categorized into low-change SCL (ΔSCL < 1.7 μs), low-change SCR (ΔSCR < 0.2 μs) and high-ABC (ABC ≥ 72%) groups. Number and location of daily steps were quantified with accelerometry and Global Positioning System devices. Compared to low-change SCL group, the high-change SCL group took fewer steps in home and community (p = 0.04). Neither ABC nor SCR groups differed in home or community steps/day. Objective measurement of PCW via electrodermal sensing more accurately represents home and community ambulation compared to the subjective questionnaire.

Co-Design of an Educational Resource with Female Partners of Male Stroke Survivors to Support Physical Activity Participation

Many male stroke survivors find it challenging to meet the recommended physical activity (PA) guidelines for health benefits. The spouse/partner is an important source of self-management for stroke survivor PA participation; however, they feel unsupported by health professionals. This study aimed to co-design an educational resource prototype to guide and empower female partners in supporting male stroke survivors' participation in PA. We used a participatory action research (PAR) methodology. Thirteen support persons of male stroke survivors from Canterbury, New Zealand participated in four PAR cycles. The data were collected using individual interviews and focus groups and analyzed inductively using the general inductive approach. Three themes were reflected in the data and informed the prototype content: (1) managing an unwanted and challenging new life, (2) inconsistent access to meaningful information, and (3) considerations for successful stroke survivor PA participation. If partners are to be an essential source in supporting stroke survivors' self-management of PA, they require resources that are meaningful and credible to enhance their confidence and self-efficacy. Further research is needed to explore the acceptability and usability of the educational resource with a wider audience and evaluate the co-design process. An inclusive and collaborative approach where support persons were valued for their expertise was essential in co-designing a meaningful resource intended to support stroke survivors and support persons' self-management of their PA.

Post-Stroke Experiences and Rehabilitation Needs of Community-Dwelling Chinese Stroke Survivors: A Qualitative Study

Stroke survivors encounter significant limitations in daily life activities and face increased risk of health complications such as stroke recurrence. Considering the escalating demand for personalised community rehabilitation services, this qualitative study was conducted to understand the current recovery experiences, needs, and expectations of community-dwelling stroke survivors. Fifty stroke survivors were recruited from two tertiary teaching hospitals and community centres in two provinces in mainland China. Semi-structured interviews were carried out, and participants were asked to describe their experiences of stroke, current lifestyles, exercise habits, and rehabilitation needs and expectations. Resulting data were thematically analysed. The majority of participants were first-time stroke survivors (80%) and lived with their family or caregivers (92%). Four main themes and twelve sub-themes emerged from the data: (1) shifts in social life, (2) shaken sense of self and perceived helplessness, (3) complex rehabilitation needs, and (4) perceptions and patterns of physical activity. Findings suggest that though survivors recognised their need for further rehabilitation, their demands remained unmet due to a combination of personal and external factors such as limited mobility and the absence of supportive companions and accessible facilities. The enhancement and diversification of home rehabilitation strategies are therefore necessary to make community rehabilitation more accessible and equitable.

Identity, social engagement and community participation impact physical activity levels of stroke survivors: A mixed-methods study

Objective

To explore how personal characteristics and social engagement impact the physical activity levels of chronic stroke survivors.

Design

A mixed-methods study comprising in-depth semi-structured interviews and objective 24-h physical activity monitoring. Interviews were thematically analysed, and activity diaries were compared to activity monitor data to attain a complete picture of physical activity. Triangulation explored the relationship between perceptions, beliefs, activity levels and social engagement.

Setting

Community.

Participants

Community-dwelling, independently mobile, adult stroke survivors (n = 19). The mean age was 74 (11 SD) years, 52% female, mean time post-stroke 41 (SD 61) months.

Main measures

Qualitative and quantitative measures including individual semi-structured interviews, accelerometry, activity diaries, self-efficacy, Frenchay Activities Index and Barthel Index.

Results

Individual identity had the greatest perceived influence on post-stroke physical activity. Pre-stroke identity, meaningful activities and family culture contributed to identity; while social and community activities, self-efficacy, co-morbidities, stroke symptoms and exercise, also impacted physical activity. Participants averaged 5365 (IQR 3378–7854) steps per day and reported a mean self-efficacy for exercise score of 51 (SD 20). Triangulation showed convergent relationships between post-stroke physical activity levels and participant motivation, comorbidities, level of social and community participation, self-efficacy and pre-stroke activity levels.

Conclusion

Personal identity, social engagement and community participation are important factors to consider when implementing a person-centred approach to increasing physical activity participation post-stroke.

Relationships Among Environmental Variables, Physical Capacity, Balance Self-Efficacy, and Real-World Walking Activity Post-Stroke

BACKGROUND

Social and physical environmental factors affect real-world walking activity in individuals with stroke. However, environmental factors are often non-modifiable, presenting a challenge for clinicians working with individuals with stroke whose real-world walking is limited due to environmental barriers.

OBJECTIVE

The purpose of this work was to test a model hypothesizing the relationships among environmental factors (specifically, living situation and area deprivation), modifiable factors, and real-world walking activity to understand opportunities for intervention. We hypothesized that balance self-efficacy would mediate the relationship between the environment and real-world walking and that physical capacity would moderate this mediation.

METHODS

This was a cross-sectional study of 282 individuals with chronic (≥6 months) stroke. We tested the indirect effect to determine if mediation was present. Multiple group structural equation modeling was used to test if physical capacity moderated this mediation. A χ² difference test was used to compare the moderation model against the null (no moderation) model.

RESULTS

Balance self-efficacy mediated the relationship between area deprivation and real-world walking (indirect effect: β = -0.04, P = .04). Both the moderation and null models fit the data equally well statistically (χ²(5) = 6.9, P = .23). We therefore accepted the simpler (null) model and concluded that the mediation was not moderated.

CONCLUSIONS

Targeting balance self-efficacy may be an effective approach to improving real-world walking in persons with stroke who experience barriers within the physical environment. A stroke survivor's physical capacity may not impact this approach. Future work should consider utilizing more specific measures of the social and physical environment to better understand their influences on real-world walking activity in individuals with stroke. However, the results of this work provide excellent targets for future longitudinal studies targeting real-world walking activity in stroke.

"Well in in this neighborhood I have walked, not at all": Stroke survivors lived experience in the outdoor environment

Stroke survivors face unique challenges in the outdoor environment when returning to their home community following a stroke. Challenges include navigating uneven terrain, social stigma, and adapting to changes in functioning. Outdoor environments may serve as potential points of intervention to promote independence and participation post stroke. This study aimed to understand lived post-stroke experience in the outdoor environment as it pertains to independent mobility.

METHODS

Qualitative semi-structured interviews were conducted with 20 stroke survivors (8 males, 12 females; mean age 64.2 years: range 45 years-90 years). Participants were eligible if they were over the age of 45, could communicate in English, lived outside a nursing home, able to walk safely outdoors, were a minimum of six-months post stroke, and had no severe cognitive impairment. Interviews with participants were tape recorded, audio files were transcribed verbatim, codes were created and applied to transcripts, and themes were generated using interpretative phenomenological analysis.

RESULTS

Post-stroke experiences in the outdoor environment were multidimensional. Three themes emerged from the stroke survivors' description of personal experiences in the outdoor environment. These themes included feelings of vigilance, employing adaptation strategies, and management of dynamic relations between the self and context.

DISCUSSION

The findings highlight the post-stroke experience traversing the outdoor environment. Investing in the public outdoor environment to remove barriers and install facilitators could reduce feelings of apprehension and hypervigilance while walking in the outdoor environment. Future research is needed to evaluate the role of environmental interventions on hypervigilance in the outdoor environment post stroke.

We Walk: a person-centred, dyadic behaviour change intervention to promote physical activity through outdoor walking after stroke-an intervention development study

OBJECTIVES

To develop We Walk, a theoretically informed, 12-week person-centred dyadic behaviour change intervention to increase physical activity (PA) in community-dwelling people with stroke (PWS) through outdoor walking.

DESIGN

Three-phase intervention development study. Phase 1: we reviewed literature on barriers and facilitators to PA after stroke and mapped them to the Behaviour Change Wheel and Theoretical Domains Framework to define intervention components. The Health Action Process Approach determined intervention structure underpinned by person-centred principles. Phase 2: stakeholder focus groups involving PWS, their companions and health professionals reviewed the draft intervention, and experts in behaviour change were consulted. Phase 3: informed by phases 1 and 2, the intervention and form of delivery were refined, with final review through patient and public involvement.

SETTING

Three Scottish community rehabilitation stroke services.

PARTICIPANTS

Twenty-three ambulatory community-dwelling PWS and their companions, thirty-seven health and exercise professionals, seven behaviour change experts.

RESULTS

Phase 1 determined key intervention components: information about benefits of walking; developing motivation and confidence to walk; facilitating dyadic goal setting and making plans together; monitoring walking, overcoming challenges; and maintaining walking behaviour. Phase 2 review by stakeholder focus groups and behaviour change experts endorsed intervention components and structure, emphasising dyadic relational aspects as central to potential success. In phase 3, intervention content and handbooks for PWS and buddies were finalised. Healthcare professionals proposed third-sector delivery as most appropriate for intervention delivery. A detailed delivery manual was developed. Participants preferred facilitated face-to-face and telephone delivery.

CONCLUSIONS

Our multilens intervention development approach ensured this novel intervention was evidence-informed, person-centred, theoretically coherent provided appropriate social support, and addressed issues of concern to PWS. This study established intervention components and structure and identified operational issues critical to future success. Future research will pilot and refine We Walk and evaluate acceptability, feasibility, effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN34488928.

The process of commitment to exercise among stroke survivors in Canada

The objective of this research was to understand the process of commitment to exercise participation for functional recovery among community-living survivors of stroke following discharge from formal rehabilitation. Participants were recruited from a mid-sized city in south-western Ontario, Canada. Between September 2017 and March 2018, 10 individuals living in the community with the effects of stroke, who continued to engage in regular exercise post-stroke, were recruited for participation. Constructivist grounded theory methodology was employed, utilising in-depth individual interviews and theoretical sampling, whereby data collection and analysis occurred simultaneously. Analysis involved constant comparison between data and codes to reduce knowledge gaps and formulate the proposed theory. The process of commitment to exercise involved four phases. Initiation of the process followed a significant interaction with a healthcare provider who advocated for participants to learn the foundations of exercise. Through planned exercise, maintenance of a positive attitude and comparisons with their pre-stroke selves and peers, participants identified future goals and imparted the desire to get back to life before stroke. Over time individuals navigated exercise opportunities-trialling different types and environments-to learn what works. Finally, participants developed a commitment to exercise as a way of life, supported by social connections and reinforced with pride in successes-mastering self-care skills, improved mobility and meaningful function. The process of commitment to exercise among survivors of stroke required early interactions with healthcare providers to initiate exercise participation for long-term engagement, and navigation through various exercise elements fuelled by a desire to reconnect with their pre-stroke selves.

The Effects of a Movement-to-Music (M2M) Intervention on Physical and Psychosocial Outcomes in People Poststroke: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of a 12-week movement-to-music (M2M) intervention on physical and psychosocial outcomes in people poststroke.

DESIGN

Two-arm randomized controlled trial.

SETTING

A community-based fitness facility.

PARTICIPANTS

Participants (N=47) with stroke between 18 and 65 years old were randomized to M2M (n=23) or waitlist control (n=24).

INTERVENTIONS

Participants in M2M completed 3 60-minute exercise sessions per week for 12 weeks. Controls received biweekly educational newsletters via mail.

MAIN OUTCOME MEASURES

Primary outcomes included Six-Minute Walk Test (6MWT, in meters), Five Times Sit-to-Stand Test (FTSST, in seconds) and Timed Up and Go (TUG, in seconds). Secondary outcomes were self-reported measures using Patient-Reported Outcomes Measurement Information System Fatigue and Pain Interference Short Form 8a. Outcomes were collected at baseline and postintervention. Analyses involved descriptive statistics and adjusted linear mixed models.

RESULTS

Mixed models adjusted for the respective baseline values and demographic variables showed that M2M participants had longer 6MWT distance (least square mean difference [LSM], 14.5; 95% confidence interval [CI], -12.9 to 42.0), more FTSST time (LSM, 2.0; 95% CI, -4.5 to 8.5), and less fatigue (LSM, -3.0; 95% CI, -7.2 to 1.2) compared with controls postintervention. When controlling for baseline TUG and demographic variables, there was a larger increase in 6MWT distance (LSM, 37.9; 95% CI, -22.7 to 98.6), lower FTSST time (LSM, -6.1; 95% CI, -18.5 to 6.2), and decrease in fatigue (LSM, -6.5; 95% CI, -13.1 to 0.2) in the M2M group compared with controls. Moderate effect sizes were observed for improving 6MWT (d=0.6), FTSST (d=-0.6), and fatigue (d=-0.6). There was no group difference in change in TUG time and pain interference, with trivial effect sizes (d=-0.1).

CONCLUSION

M2M may be a valuable exercise form for adults with stroke. Future studies are needed to determine optimal exercise doses for improving health and function in this population.

Qualitative study of Stroke Survivors' Perceptions of Secondary Prevention

AIMS

To understand how survivors of stroke perceive secondary prevention and explore their perceived barriers and facilitators using the Theoretical Domains Framework.

DESIGN

A qualitative descriptive study.

METHODS

Nineteen survivors of stroke from three hospitals were recruited and interviewed from April 2019 to April 2020. The data were analysed deductively and inductively by content analysis strategies.

RESULTS

Three main themes of perception of secondary prevention were identified, these being active treatment-seeking, attention to taking medications and negative attitude towards lifestyle changes. Using deductive analysis, eight domains of the Theoretical Domains Framework were reported to be relevant in the secondary prevention behaviour of survivors of stroke that mapped to five 'barrier' domains (i.e. knowledge, physical skills, beliefs about capability, beliefs about consequences and optimism) as well as six 'facilitator' domains (i.e. knowledge, interpersonal skills, beliefs about capability, intention, emotion and social influences). Using inductive analysis we identified two additional important factors not falling in the domains of the Theoretical Domains Framework. These comprised female spouses' support and patients' economic autonomy, both of which could be classified as a facilitator or barrier.

CONCLUSION

Survivors of stroke perceive seeking treatment and using preventive medication as more important than modifying lifestyle behaviours. Knowledge and insight into the barriers and facilitators of secondary prevention in this specific context provides a theoretical and practical basis for the design of future secondary prevention interventions.

IMPACT

Stroke survivors' perceptions of secondary prevention, barriers and facilitators were explored in the context of a developing country. These findings highlight the need to better communicate the importance of improving lifestyle modification and medication adherence, and provide evidence for designing relevant interventions for stroke management in the community.

To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES

This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke.

MATERIALS AND METHODS

Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity.

RESULTS

At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R² = 0.087, P = 0.040).

CONCLUSIONS

Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Beyond Physical Capacity: Factors Associated With Real-world Walking Activity After Stroke

OBJECTIVE

To identify homogeneous subsets of survivors of chronic stroke who share similar characteristics across several domains and test if these groups differ in real-world walking activity. We hypothesized that variables representing the domains of walking ability, psychosocial, environment, and cognition would be important contributors in differentiating real-world walking activity in survivors of chronic stroke.

DESIGN

Cross-sectional, secondary data analysis.

SETTING

University/laboratory.

PARTICIPANTS

A total of 283 individuals with chronic (≥6mo) stroke (N=238).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Thirteen variables representing 5 domains were included: (1) walking ability: 6-minute walk test (6MWT), self-selected speed (SSS) of gait; (2) psychosocial: Patient Health Questionnaire-9, Activities-specific Balance Confidence (ABC) scale; (3) physical health: low-density lipoprotein cholesterol, body mass index, Charlson Comorbidity Index (CCI); (4) cognition: Montreal Cognitive Assessment (MoCA); and (5) environment: living situation and marital status, work status, Area Deprivation Index (ADI), Walk Score. Mixture modeling was used to identify latent classes of survivors of stroke. After identifying the latent classes, walking activity, measured as steps per day (SPD), was included as a distal outcome to understand if classes were meaningfully different in their real-world walking RESULTS: A model with 3 latent classes was selected. The 6MWT, SSS, ABC scale, and Walk Score were significantly different among all 3 classes. Differences were also seen for the MoCA, ADI, and CCI between 2 of the 3 classes. Importantly, the distal outcome of SPD was significantly different in all classes, indicating that real-world walking activity differs among the groups identified by the mixture model.

CONCLUSIONS

Survivors of stroke with lower walking ability, lower self-efficacy, lower cognitive abilities, and greater area deprivation had lower SPD. These results demonstrate that the physical and social environment (including socioeconomic factors) and cognitive function should also be considered when developing interventions to improve real-world walking activity after stroke.

Exploring the factors influencing the use of electrically assisted bikes (e-bikes) by stroke survivors: a mixed methods multiple case study

PURPOSE

E-bikes have the potential to overcome some of the barriers that stroke survivors face with regards to physical activity. This study aims to explore the factors that affect e-bike usage by stroke survivors.

METHODS

A mixed methods multiple case studies design, using semi-structured interviews and GPS data. Subject to GP approval, participants loaned an e-bike or e-trike for up to three months. Interviews were undertaken pre and post intervention. The COM-B behaviour change model acted as a framework for analysis. GPS data relating to journey duration and distance travelled was collected fortnightly.

RESULTS

Six participants were recruited; only three loaned an e-bike/e-trike (with adaptations as required). Storage, being unable to get GP approval, and safety were withdrawal reasons. Level of impairment was a factor influencing the type of e-bike used, level of support required and the motivation of the participants.

CONCLUSION

Stroke survivors can use e-bikes although barriers exist. Electrical assistance was a positive factor in enabling some of the participants to cycle outdoors. Due to the small sample size and the number of participants who were able to loan an e-bike, further research is required to determine whether e-bikes are a feasible and effective intervention to increase physical activity for stroke survivors.IMPLICATIONS FOR REHABILITATIONThe assistance provided by the e-bike/e-trike could provide stroke survivors the opportunity to cycle outdoors.E-bikes/e-trikes could facilitate participation of activities of everyday living such as shopping, hobbies and increase levels of physical activity.Rehabilitation could focus on physical impairment, its effects on self-confidence, and knowledge surrounding the e-bike to overcome barriers to cycling.Social support, the belief that e-bike was an enjoyable mode of physical activity that was good for their health were reported by the participants as important factors for using the e-bike/e-trike.

Social and physical environmental factors in daily stepping activity in those with chronic stroke

BACKGROUND, PURPOSE/OBJECTIVE

Walking behavior in the chronic stroke population is multi-factorial. Previous work focused on the role of physical and biopsychosocial factors in understanding daily stepping post stroke. However, qualitative evidence suggests that social and physical environmental factors also affect daily stepping in those with stroke. The purpose of this study was to understand the role of social and physical environmental factors in daily stepping after stroke.

METHODS

A total of 249 individuals ≥6 months post stroke were included in this cross-sectional analysis (129 females, mean age 62.98 years, SD 11.94). The social environment included living situation, work status, and marital status. The physical environment included the Area Deprivation Index (ADI) and Walk Score. At least 3 days of stepping was collected using an accelerometry-based device. Predictors were entered sequentially into a regression model: demographic characteristics, social environmental factors, and physical environmental factors.

RESULTS

After adjusting for demographic factors, social environmental factors explained 6.2% (p =.017) of the variance in post stroke daily stepping. The addition of physical environmental factors improved the model (ΔR² =.029, p =.024). The final model explained 9.2% (p =.003) of the variance in daily stepping. Lower area deprivation (ADI β = -0.178, p =.015) and working (working vs. retired β = -0.187, p = .029 and working vs. unemployed β = -0.227, p =.008) were associated with greater daily stepping.

DISCUSSION/CONCLUSION

Social and physical environmental factors predicted daily stepping and should be considered when setting expectations relative to the effects of rehabilitation on daily stepping in individuals poststroke.

Multi-Level Factors Associated with Social Participation among Stroke Survivors: China's Health and Retirement Longitudinal Study (2011-2015)

Background: This study aims to examine the impact of individual-level and community-based factors on popular social participation activities of Chinese middle-aged and older adults post-stroke. Methods: Sub-samples of survivors of stroke (2011: n = 413, 2013: n = 395, 2015: n = 441) recruited by the China Health and Retirement Longitudinal Study (CHARLS) were included in the analysis. Zero-inflated Poisson and multi-level logistic regression models were used to explore factors associated with social participation. Results: More than half of individuals (55.0%) had no social participation and 23.4% participated in multiple social activities. The most popular social activities that individuals participated in were interacting with friends (32.6%) and going to a community club to play table games (22.7%). Multiple individual-level factors were negatively related to social participation (e.g., depressive symptoms and multiple measures of functional limitations) while the allocation of an outdoor exercise facility in the community/village was positively associated with going to a community club to play table games. Conclusion: Stroke survivors are at high risk of limited social participation. Policymakers and other key stakeholders should consider community design among other potential solutions when identifying ways to link at-risk stroke survivors to both opportunities for rehabilitation (e.g., physical function) and social participation.

Perceived barriers and facilitators for gait-related participation in people after stroke: From a patients' perspective

Background: An important focus of post-stroke physical therapy is to improve walking and walking capacity. However, many people after stroke experience difficulties with gait-related participation, which includes more than walking capacity alone. Gait-related participation involves walking with a participation goal and requires to deal with changes in the environment during walking and perform dual tasks, for example.Objective: To explore barriers and facilitators for gait-related participation from the perspective of people after stroke. This knowledge can contribute to the development of effective interventions to improve gait-related participation.Methods: Semi-structured interviews were conducted to investigate how people after stroke experience gait-related participation. Audio-recorded interviews were transcribed, anonymized, and analyzed thematically. Barriers and facilitators were categorized according to the International Classification of Functioning, Disability and Health (ICF) framework.Results: Twenty-one people after stroke participated. Median age was 65 years, median time since stroke 16 weeks. Barriers were reported in movement-related functions, cognitive functions, mobility, personal factors, and environmental factors. Facilitators were found on participation level and in personal and environmental factors, such as motivation and family support.Conclusion: People after stroke who were physically able to walk independently still described multiple barriers to gait-related participation in all components of the ICF framework.

Development and Validation of a Questionnaire to Assess Barriers to Physical Activity After Stroke: The Barriers to Physical Activity After Stroke Scale

OBJECTIVE

To develop and validate a self-reported questionnaire assessing the barriers to physical activity (PA) among stroke survivors.

DESIGN

Psychometric study.

SETTING

Ambulatory stroke care.

PARTICIPANTS

A total of one hundred and forty-six (N=146) individuals were included in this study. In stage 1, community-living stroke survivors (n=37; 13 women) with low-moderate disability (modified Rankin Score 0-3, stroke >3mo) were included. In stage 2, participants (n=109; 40 women) with same characteristics were included. Nine professionals experienced in PA for poststroke patients formed an expert panel.

INTERVENTIONS

In stage 1, semistructured interviews identified perceived barriers to PA, which were then selected by the expert panel and grouped on a Barriers to Physical Activity After Stroke (BAPAS) scale. In stage 2, stroke participants completed a personal information questionnaire and the BAPAS scale.

MAIN OUTCOME MEASURES

An item selection process with factor analysis was carried out. The suitability of the data set was analyzed using the Kaiser-Meyer-Olkin coefficient, internal consistency was evaluated by Cronbach α, and concurrent validity was assessed with Spearman correlation coefficients between the BAPAS scale and the modified Rankin Scale. Test-retest repeatability was estimated using 2-way random effects intraclass correlation coefficient model 2,1 at 4-6 day follow-up (n=21).

RESULTS

Factor analysis supported a 14-item BAPAS that explained 62% of total variance (Kaiser-Meyer-Olkin=0.82) and total score calculated higher than 70 (higher scores for higher barriers). Cronbach α was 0.86, Spearman correlation with the modified Rankin Scale was r=0.65 (P<.001), and test-retest intraclass correlation coefficient was 0.91 (95% CI, 0.79-0.97). The BAPAS scores were higher in patients with greater disabilities and in those with a longer time since the stroke event (P<.01).

CONCLUSION

We developed and validated the BAPAS scale to assess barriers to PA in stroke survivors with low-moderate disability with promising psychometric properties.

Walking activity and its determinants in free-living ambulatory people in a chronic phase after stroke: a cross-sectional study

Background: Free-living walking activity and its contributing factors in ambulatory people with stroke is poorly investigated.Objective: Evaluating free-living walking activity and identifying factors associated with free-living walking activity.Methods: In this cross-sectional study, participants wore an accelerometer to measure their level of walking activity. They also completed the Berg Balance Scale (BBS) and the Timed Up and Go test for functional balance, the Falls Efficacy Scale, the 10-Metre Walk Test and the Geriatric Depression Scale to investigate the relation between the performance tests and walking activity.Results: The 38 analyzed participants were on average 62 (±11.4) years old and 66 (IQR 64.8) months post stroke. They took an average of 3048.3 ± 1983.1 steps, had 123.3 ± 61.3 walking bouts a day and walked for 32.5 ± 18.2 min a day. Their average speed was 90.3 ± 13.8 steps a minute. The multivariate linear analysis showed that the BBS was the only determinant that was significantly related to all outcomes, except walking bouts.Conclusion: Free-living walking activity levels in ambulatory people with chronic stroke are low. The BBS is an independent significant predictor of free-living walking activity.Implications for rehabilitationFree-living walking activity can be expressed in different outcomes measured by accelerometry.Free-living walking activity levels in ambulatory people with chronic stroke are low, therefore support to sustain walking in the own environment should be part of the rehabilitation program after stroke.Balance is an important related factor to free-living walking activity which needs attention during rehabilitation after stroke.

Previous experience and walking capacity predict community outings after stroke: An observational study

Background: Following hospital discharge, stroke survivors may experience a decline in mobility, outings, and community participation. The aim of this study was to examine the relationship between demographic and clinical measures, and the level of participation by community-dwelling stroke survivors. Methods: A prospective, multicenter, observational study was conducted. Participants were 83 community-dwelling stroke survivors with participation goals who were undergoing post-inpatient rehabilitation in Australia. Predictors collected at baseline, early after hospital discharge were demographic (age, gender, living situation, home access) and clinical measures (walking capacity, driving status, baseline outings). The outcome of interest was community participation 6 months later, measured over 7 days as number of outings (collected in a self-report diary). An outing was any excursion beyond the perimeter of the participants' dwelling into a public street. Results: Number of outings 6 months after admission to the study (mean 8.5/week, SD 5.3) was predicted by number of outings at baseline, walking capacity, and age. Driving status did not predict number of outings. Conclusion: The strongest predictors of community participation were the number of outings early post-inpatient rehabilitation, walking capacity, and age. The only significant modifiable predictor was walking capacity.

Ten Meters Walking Speed in Spinal Cord-Injured Patients: Does Speed Predict Who Walks and Who Rolls?

BACKGROUND

Walking speed is assumed to be a key factor in regaining ambulation after spinal cord injury (SCI). However, from the literature it remains unclear which walking speed usually results in independent community ambulation.

OBJECTIVE

The primary aim of this study was to determine at which walking speed SCI patients tend to walk in the community instead of using a wheelchair. The secondary aim was to investigate clinical conditions that favor independent ambulation in the community.

METHODS

Data from SCI patients were collected retrospectively from the European Multicenter Study about Spinal Cord Injury database. We determined a cutoff walking speed at which the patients tend to walk in the community by plotting a receiver operating characteristics curve, using the Spinal Cord Independence Measure for outdoor mobility. Univariate analyses investigated which factors influence independent community ambulation.

RESULTS

A walking speed of 0.59 m/s is the cutoff between patients who do and do not ambulate independently in the community, with a sensitivity of 91.6% and a specificity of 80.3%. Age, injury severity, and lower limb muscle strength have a significant influence on independent community ambulation.

CONCLUSIONS

Patients with an SCI who regain a walking speed of 0.59 m/s tend to achieve a level of walking effectiveness that allows for independent community walking. Although such patients tend to be younger and less severely injured, this walking speed can be a target for locomotor training in rehabilitation and clinical trials that lead to a meaningful outcome level of community walking.